Child/Teen Concerns - Jeffrey Bernstein, Ph.D.


ADHD

Dr. Bernstein specializes in helping children, teens and adults with ADHD. He also advises parents, teachers and others who are responsible for the health and development of young people with ADHD.

Treatments/Issues

Psychological Issues Often Seen in ADHD Children & Adolescents.

Low self-esteem is a common complication. This may result from chronic academic underachievement/failure, social difficulties, or behavioral problems. Affected children/adolescents report:

  • lower expectations
  • Anxiety or depression due to a feeling of "not fitting in"
  • School absenteeism, an unwillingness to attempt new tasks, or resignation may be evident
  • Loss of motivation/chronic failure and criticism may result in "learned helplessness" or in maladaptive, face-saving tactics.
  • Alcohol and drug use along with disruptive behavior can also occur in time, particularly in the midst of longstanding academic and family problems.

Treatment Goals for Children & Adolescents with ADHD.

  1. To enhance child's insight and parents' understanding of attention deficits and related problems.
  2. To target most maladaptive behavioral traits for special insight and specific management.
  3. To set reasonable and realistic expectations and goals.
  4. To identify associated processing problems or learning disabilities that compromise school performance.
  5. To identify complications and secondary effects such as social or emotional problems and family dysfunction.
  6. To improve interactions with parents, teachers, and peers.
  7. To strengthen communication between home and school.
  8. To mobilize child/adolescent's strengths and resources.

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ADHD Impairments

Cognitive

Mild deficits in intelligence (approximately 7-10 points).
Deficient achievement skills (range of 10-30 standard score points).
Learning disabilities: reading (8-39%), spelling (12-26%), math (12-33%), and handwriting (common but unstudied).
Poor sense of time inaccurate time estimation and reproduction.
Decreased nonverbal and verbal working memory and impaired planning ability.
Reduced sensitivity to errors.
Impairment in goal-directed behavioral creativity.

Language

Delayed onset of language (up to 35% but not consistent).
Speech impairments (10-54%).
Excessive conversational speech (commonplace), reduced speech to confrontation.
Poor organization and inefficient expression of ideas.
Impaired verbal problem solving.
Coexistence of central auditory processing disorder (minority but still uncertain).
Poor rule-governed behavior.
Delayed internalization of speech (up to 30% delay).
Diminished development of moral reasoning.

Adaptive functioning:

10-30 standard score points behind normal.
Motor development
Delayed motor coordination (up to 52%).
More neurological "soft" signs related to motor coordination and overflow movements.
Sluggish gross motor movements.


Emotion

Poor self regulation of emotion.
Greater problems with frustration tolerance.
Under active arousal system.

School Performance

Disruptive behavior (commonplace).
Under performing in school relative to ability (commonplace).
Academic tutoring (up to 56%), Repeat a grade (30% or more).
Placed in one or more special education programs (30-40%).
School suspensions (up to 46%) expulsions (10-20%).
Failure to graduate high school (10-35%).

Task Performance

Poor persistence of effort/motivation.
Greater variability in responding.
Decreased performance/productivity under delayed rewards.
Greater problems when delays are imposed within the task and as they increase in duration.
Decline in performance as reinforcement changes from being continuous to intermittent.
Greater disruption when noncontingent consequences occur during the task.

Medical/Health risks

Greater proneness to accidental injuries (up to 57%).
Possible delay in growth during childhood.
Difficulties surrounding sleeping (up to 30-60%).
Greater driving risks: vehicular crashes and speeding tickets.

*From: Russell Barkley (1998), Attention Deficit Hyperactivity Disorder, A Handbook for Diagnosis and Treatment.


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ADHD Interventions

*Note: The following list of strategies is representative and not meant to be exhaustive. Medical, Mental Health, and Educational professionals should be involved when such interventions are implemented for individuals with ADHD.

Children/Adolescents at School

  • Ensure ongoing parent and school communication (get and stay involved).
  • Break down large tasks into small tasks.
  • Provide EMPATHY, EMPATHY, EMPATHY.
  • Provide extra time for exams and projects.
  • Pay attention to the emotions involved in the learning process.
  • Repeat directions. Write down directions. Speak clear directions.
  • Seat the ADHD child near the teacher's desk or wherever you are most of the time.
  • Set limits and boundaries but not in a punitive way.
  • Go for quality rather than quantity of homework.
  • Outline, underline.
  • Simplify instructions, choices, and scheduling.
  • Make expectations explicit and emphasize success.
  • Pay attention to "connectedness."
  • Assist with drug therapies (staff supervised).
  • Encourage student-mediated conflict resolution programs.

Children/Adolescents at Home

  • Use reinforcement programs (not as bribery but for increased motivation).
  • Provide EMPATHY, EMPATHY, EMPATHY.
  • Consider drug therapies.
  • Increase structure at home to help child/teen complete school work.
  • Eliminate shaming and blaming, e.g. comparisons to non-ADHD siblings and peers.
  • Develop clear expectations but also be willing to re-evaluate them in the face
  • of changing situations or circumstances.

Treatment Strategies for Adults

  • Seek individual counseling (for coexisting problems of depression, anxiety, low-self
  • esteem, interpersonal problems, and disorganization).
  • Seek family/marriage counseling (useful for resolving difficulties that affect
  • relationships family members, spouses and partners). Non-ADHD spouses often report
  • feeling confused, angry, and frustrated. Both patients and spouses need EMPATHY.
  • Consider vocational counseling (to address impulsivity, inattention, careless.
  • mistakes, disorganization, poor time management, and inconsistency that can interfere
  • in job performance).
  • Consider drug therapies.

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Drug Treatments

An Overview of Drug Treatments Used for Individuals with ADHD.

Note: Medications do not teach individuals with ADHD anything. They merely increase the probabilities of these individuals displaying helpful behaviors already in their repertoire.

Stimulants

While not a panacea, stimulants are the treatment modality to date that most normalize inattentive, impulsive, and overactive behavior in children, adolescents and adults with ADHD. The five most commonly employed stimulants are Ritalin, Concerta, Dexedrine, Cylert, and Adderall (a combination of amphetamine and dextroamphetamine). Benefits of these medications are improved attention, impulse control, task-irrelevant activity, academic productivity and accuracy, handwriting, play, social conduct, and/or compliance to commands or rules. Side effects can include insomnia, decrease appetite, anxiety, sadness, tics or nervous movements, and dizziness.

Antidepressants

Antidepressants also play an important role as a treatment for individuals with ADHD, particularly for those who do not respond to stimulants. Tricyclic antidepressants are the most established non-stimulant agents used in the treatment of ADHD. These include Norpramin, Pamelor, and Tofranil. Selective Seritonon Reuptake Inhibitors are also used such as Prozac and Zoloft. It is important to note that in addition to addressing the core ADHD symptoms, antidepressants are also helpful in addressing comorbid symptoms (depression, anxiety, aggression, obsessive-compulsiveness) that may accompany ADHD. Antidepressants can be used along with stimulant medications in some cases.

Other Medication for the Treatment of ADHD

Other medications may provide hope for some ADHD patients who do not respond to more conventional therapies. These include antihypertensive agents such as Clonidine and Guanfacine (both of which may help to reduce aggression and impulsivity). For children with comorbid Tourette Syndrome or tic disorder, antipsychotic medications (e.g., Thioridazine, haloperidol) may help.

Medications Not Found Useful in the Treatment of ADHD

Fenfluramine, antihistamines, benzodiazepines, lithium, caffeine.

*Adapted From: Russell Barkley (1998), Attention Deficit Hyperactivity Disorder, A Handbook for Diagnosis and Treatment.


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ADHD Research Findings

A National Perspective on Treatment Services for ADHD

What have been the important trends during the past decade in the type of care that children with ADHD typically receive in community settings? As you can imagine, this is a difficult and complicated question to address. The answer to this question is enormously important, however, for it will inform us about critical gaps in the provision of appropriate care that parents need to be aware of and that professionals and policy makers need to address.

A recent article from the Journal of the American Academy of Child and Adolescent Psychiatry (JAACP) provides the most comprehensive information yet available on this issue (Hoagwood, K. et al., (2000). Treatment services for children with ADHD: A national perspective. JAACP, 39, 198-206). There is a tremendous amount of interesting data presented in this paper, and I will try to highlight what seem to be the key findings below.

Data for this study come from two large national data bases that were established in the 1980s and updated annually since then. These data bases include representative samples of pediatricians, family physicians, and psychiatrists who provide records of patient visits, diagnoses, and services provided at each visit. (All information that could potentially identify any patient is removed so that records remain anonymous.) By comparing the kinds of services provided to children who had been identified as having a diagnosis of ADHD, and noting the types of services that these children received, trends in service provision over the recent past can be identified. This is because these data are based on thousands of community physicians who treated thousands of children and teens for ADHD. Even though the exact same physicians did not provide data in different years, the sample is large enough, and representative enough, to provide a good picture of what is actually going on.

Results

The results of this study are fascinating. Here are some of the key findings:

* ADHD is being identified at a greater rate

The percentage of visits where ADHD was identified has risen from .74% in 1989 to 1.9% in 1996. In addition, for physician visits where a mental health problem was identified as the primary reason for the visit, the percentage of children identified as having important attentional problems increased from 41% to 60% during this same period.

Note: Although these data indicate that ADHD is being identified at an increased rate, 2 points are important to keep in mind. First, these data tells us nothing about the accuracy of the diagnoses being made. Second, the 1.9% rate for physician- identified ADHD in 1996 is still substantially below actual prevalence rates that have been determined from a number of different studies. Overall, therefore, it may be that many instances of ADHD continue to go undiagnosed and untreated.

* Important changes are occurring in medication management

The percentage of visits for children with ADHD during which stimulants were prescribed increased from about 55% in 1989 to about 75% in 1996. During that time, there was a corresponding decline in the prescription of other medications to treat ADHD from about 15% in 1989 to about 7.5% in 1996.

Note: Because stimulant medication has been shown to be an effective treatment for most children with ADHD, the fact that more children are receiving it may reflect physicians' greater use of an empirically validated treatment approach. Unfortunately, no data is available on the quality and care of the medication treatment being practiced. As you may recall from the results of the MTA study (http://www.helpforadd.com/mta.htm) (i.e. the largest and most comprehensive treatment study of ADHD conducted to date) there is good reason to believe that children treated with medication in the community typically do not derive as much benefit as they might were careful and systematic procedures followed. I think it is encouraging that the rate of prescribing non-stimulant medications for children with ADHD has been cut dramatically.

The reason for this is that non-stimulant meds are typically less effective and less is known about their long-term safety. In the MTA study, however, almost none of the children with ADHD required medications other than stimulants to effectively manage their symptoms. This suggests that in many cases where other meds are prescribed, it may be because careful efforts to obtain the greatest possible benefits from stimulant medications were not used. Thus, the 7.5% figure may still reflect a greater use of alternative medications than is really necessary.

* There has been an important decline in important follow-up care for children with ADHD

Between 1989 and 1996, the percentage of visits where follow-up care was recommended declined from 91% to 75%. Thus, as recently as 1996, 25% of children identified as having ADHD are not scheduled for any follow-up care.

Note: I am very concerned about this finding. Because ADHD typically affects children over many years, one of the most important aspects of treatment is carefully monitoring a child's development over time. Just because a child's symptoms are being managed effectively at one point in time does not, unfortunately, mean that this will persist. Difficulties often emerge and require that adjustments to a child's treatment be made. It is virtually inconceivable that effective care could be provided in the absence of regular and periodic follow-ups. (The ADHD Monitoring System by Dr. David Rabiner can be an effective tool to help you monitor your child's progress and functioning over time, although this gets more difficult to do when children move into middle school and begin to have multiple teachers. If you do not have the monitoring system, just mail to: monitor@helpforadd.com.

The authors also examined how the type of services that children with ADHD received varied according to whether the provider was a pediatrician, family physician, or psychiatrist. These results are based on the most recently available data, which was from 1996.

The major findings here are that family physicians are more likely than the other providers to prescribe stimulant medication for treating ADHD (i.e. 95% vs. about 75% for pediatricians and psychiatrists). Conversely, family physicians were less likely to utilize any type of formalized diagnostic services in their visits with children identified as having ADHD (i.e. 33% vs. 64% for pediatricians and about 80% for psychiatrists). Family physicians were also less likely to recommend specific follow-up care (i.e. 46% vs. 79% for pediatricians and 89% for psychiatrists). Family physicians were also far less likely to provide any type of mental health/behavioral counseling services during visits - only 7% of the time - than were pediatricians (44%) or psychiatrists (67%).

Note: Although this study does not include any data that enables one to determine the appropriateness of services being provided, it does appear that the care a child receives depends greatly on the type of physician doing the treatment. In particular, although family physicians were more likely to prescribe stimulant medication, they were less likely to use any formalized diagnostic services, to provide any type of counseling, or to even recommend follow-up care. Even among pediatricians and psychiatrists, follow- up care often failed to be recommended, and it seems highly unlikely that this was because no such care would have been needed.

Overall, the authors conclude that in at least 50% of the cases, guidelines for care that have been recommended by the American Academy of Child and Adolescent Psychiatry for the treatment of ADHD are not being followed. This is not good news.

Barriers to Care

The final issue examined in this study concerned what primary care physicians (i.e. pediatricians and family physicians) perceived as the major obstacles to making mental health referrals they may have felt were needed for their patients with ADHD. Listed below are some of the barriers they identified along with the % of the physicians surveyed who reported each barrier:

  • Barriers % reporting
  • Lack of specialists 64%
  • Difficulty getting appt. 64% Restrictions on who could be 48% referred to because of insurance company
  • Authorization procedures 39%
  • Financial disincentives 35%
  • Burdensome paperwork 30%

The two most commonly reported barriers, mentioned by nearly two-thirds of participating physicians, reflect the perceived lack of clinicians who are specially trained to work with child behavior problems (e.g. child psychiatrists , child psychologists, developmental pediatricians). The other commonly reported barriers to care appear to be direct outgrowths of the restrictions placed on mental health treatment by many of today's health maintenance organizations. It is particularly striking to me that over one-third of the physicians surveyed reported that financial disincentives limited the number of mental health referrals they made for children. Although these data do not provide direct evidence that the quality of care that children receive as a result of HMO regulations has been compromised, it is certainly consistent with this hypothesis.

Summary and Implications

The most important implication of this study according to the authors is as follows:

"Although at least 2 professional associations have written guidelines or parameters of practice with these children (American Academy of Child and Adolescent Psychiatry and American Academy of Pediatrics), and though evidence-based reviews have been completed, these guidelines are not yet influencing care as delivered in real-world practices."

To this conclusion I would add that these data strongly suggest that changes in the insurance industry and the restrictions these changes have placed on many physicians is likely to be having a negative effect on the quality of care that many children with ADHD - as well as children with other types of emotional and behavioral problems - receive. To me, this highlights how important it is for parents to be as informed as possible about how ADHD can affect children's development and what are the best ways to promote the long-term success of children with ADHD.


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Classroom Tips

Tips on the Classroom Management of Young Children with Attention Deficit Hyperactivity Disorder (ADHD).

As many caregivers and teachers know, ADHD can manifest itself in many forms in young children. Some children may appear highly overactive while others may seem "spacey". Often ADHD later appears entangled with several other problems such as learning disabilities, mood problems, or personality difficulties. ADHD features and their severity are also often unpredictable. Furthermore, the treatment for ADHD, continues to be a task of hard work and devotion.

There is no easy solution for the management of ADHD in the classroom, or at home for that matter. The bottom line is that the effectiveness of any treatment for this disorder at school depends upon the knowledge and the persistence of the school, individual teacher/caregiver, and parents.

Below are tips for the school management of children with ADHD. The following suggestions are intended for teachers of young children. The overall themes of structure, proactive measures, education, and encouragement pertain to all of the strategies. These tips represent a combination of several sources of information which are included at the end as references for more in-depth information.


1. Keep in mind that the diagnosis of ADHD in young children (particularly below age 5) is a complex process. It is definitely not up to the teacher to diagnose ADHD, but you can and should raise questions. Most importantly, inquire (tactfully) if the problem behaviors have been brought to the attention of a qualified health/mental health professional. The responsibility for seeing to this is the parents', not the teacher's, but the teacher can support the process.

2. Distinguish incompetence from noncompliance: If the child can't control his/her behavior it is not noncompliance, therefore, you can't blame.

3. Break down large tasks into small tasks. This is one of the most crucial of all instructional techniques for children with ADHD. Large tasks quickly overwhelm the child and he recoils with an emotional "I CAN'T DO THAT" kind of response. By breaking the task down into manageable parts, each component looking small enough to be do-able, the child can sidestep the emotion of being overwhelmed. In general, these kids can do a lot more than they think they can. By breaking tasks down, the teacher can let the child prove this to himself or herself. With small children this can be extremely helpful in avoiding tantrums born of anticipatory frustration. And with older children it can help them avoid the defeatist attitude that so often gets in their way. And it helps in many other ways, too. You should do it all the time.

4. Be sure to give positive feedback when appropriate. This is so important because children with ADHD often hear so much negative feedback.

5. Provide Extra Time for completing tasks: Permitting additional time can allow for the difficulties with attention common to many students with ADHD.

6. Build support for yourself. Being a teacher in a classroom where there are two or three kids with ADHD can be exhausting. Make sure you have the support of the parents. Consult when you have a problem (learning specialist, child psychologist, social worker, school psychologist, or pediatrician. Make sure the parents are working with you.

7. Know your limits. Don't be afraid to ask for help. You, as a teacher, cannot be expected to be an expert on ADHD. You should feel comfortable in asking for help when needed.

8. Ask the child what will help. These young people are often very intuitive. They can tell you how they can learn best if you ask them. They are often too embarrassed to volunteer the information, but try to sit down with the child individually and ask how he or she learns best. By far the best "expert" on how the child learns is the child himself or herself.

9. Remember that ADHD kids need structure. They need their environment to structure externally what they can't structure internally on their own. Make lists. Liberally give repetition, direction, set limits and structure.

10. Remember the emotional part of learning. These children need special help in finding enjoyment in the classroom, mastery instead of failure and frustration, excitement instead of boredom or fear. It is essential to pay attention to the emotions involved in the learning process.

11. Repeat directions. Write down directions. Speak directions. Let them hear things more than once.

12. Make frequent eye contact. You can "bring back" an ADHD child with eye contact. Do it often. A glance can retrieve a child from a daydream or give permission to ask a question of just give silent reassurance.

13. Seat the ADHD child near the teacher most of the time. This helps prevent drifting away..

14. Set limits and boundaries but not in a punitive way. Do it consistently, predictably, promptly, and plainly. DON'T get into complicated, lawyer-like discussions of fairness.

15. Have as predictable a schedule as possible. Post it on the blackboard or the child's desk. Refer to it often. If you are going to vary it, as most interesting teachers do, give lots of warning and preparation. Transitions and unannounced changes are very difficult for these children. They become discombobulated around them. Take special care to prepare for transitions well in advance. Announce what is going to happen, then give repeat warnings as the time approaches.

16. Allow for escape valve outlets such as leaving class for a moment. If this can be built into the rules of the classroom, it will allow the child to leave the room rather than "lose it," and in so doing begin to learn important tools of self-observation and self-modulation.

17. Monitor progress often. Children with ADHD benefit greatly from frequent feedback. It helps keep them on track and lets them know what is expected of them.

18. Use Time Out: Remove the child from opportunities for reinforcement. Be sure the "time out" environment is not reinforcing. This is important because ADHD children "heat up" and time out procedures provide an opportunity to "cool down".

19. Let yourself be playful, have fun, and be unconventional. Introduce novelty into the day. Children with ADHD love novelty. They respond to it with enthusiasm. It helps keep attention -- the kids' attention and yours as well. These children are full of life -- they love to play. And above all they hate being bored. So much of their "treatment" involves boring stuff like structure, schedules, lists, and rules, you want to show them that those things do not have to go hand in hand with being a boring person, a boring teacher, or running a boring classroom. Every once in a while, if you can let yourself be a little bit silly, that will help a lot.

20. Seek out and underscore success as much as possible. These kids live with so much failure, they need all the positive handling they can get. This point cannot be overemphasized: these children need and benefit from praise. They love encouragement. They drink it up and grow from it. And without it, they shrink and wither. Often the most devastating aspect of ADHD is not the ADHD itself, but the secondary damage done to self-esteem. So water these children well with encouragement and praise.

21. Memory is often a problem with these kids. Teach them little tricks-- cues, rhymes, code and the like -- can help a great deal to enhance memory.

22. Announce what you are going to say before you say it. Say it. Then review what you have said. Since many ADHD children learn better visually than by voice, if you can write what you're going to say as well as say it, that can be most helpful. This helps "glue" the ideas in place.

23. Simplify instructions. Simplify choices. Simplify scheduling. The simpler the verbiage the more likely it will be comprehended. And use colorful language. Like color coding, colorful language keeps attention.

24. Use feedback that helps the child become self-observant. Children with ADHD often have no idea how they come across or how they have been behaving. Be constructive. Ask questions like, "Do you know what you just did?" or "How do you think you might have said that differently?" or "Why do you think that other girl looked sad when you said what you said?" Ask questions that promote self-observation.

25. Make expectations explicit.

26. A point system is a possibility as part of a behavioral modification or reward system for younger children. Children with ADHD respond well to rewards and incentives.

27. If the child seems to have trouble reading social cues -- body language, tone of voice, timing and the like -- try discreetly to offer specific and explicit advice as a sort of social coaching. For example, say "Before you tell your story, ask to hear the other person's first," or, "Look at the other person when he's talking." Many children with ADHD are viewed as indifferent or selfish, when in fact they just haven't learned how to interact.

28. Make a game out of things. Motivation improves ADHD.

29. Separate pairs and trios, whole clusters even, that don't do well together.

30. Pay attention to "connectedness". If engaged, ADHD kids will less likely to tune out.

31. Enforce the home-to-school-to-home notebook. This can really help with the day-to-day parent-teacher communication and avoid the crisis meetings. It also helps with the frequent feedback these kids need.

32. Try to use daily progress reports.

33. Encourage a structure for self-reporting, self-monitoring. Brief exchanges at the end of class can help with this. Consider also timers, buzzers, etc.

34. Prepare for unstructured time. These kids need to know in advance what is going to happen so they can prepare for it internally. Spontaneous unstructured time can be over-stimulating.

35. Praise, stroke, approve, encourage, and nourish.

36. Explain and normalize the treatment the child receives to avoid stigma.

37. Meet with parents often. Avoid the pattern of just meeting around problems.

38. Recommend exercise. One of the best treatments for ADHD is exercise, preferably vigorous exercise. Exercise helps work off excess energy, helps focus attention, stimulates certain hormones and neurochemicals that are beneficial, and it is fun. If it is fun, the child will more likely continue to do it.

39. Always be on the lookout for sparkling moments. These kids are far more talented and gifted than they often seem. They are often highly creative. They tend to be resilient but still need much support.

The above information was adapted from the following resources:
Crutsinger, M.S. & Moore, D. ADD Quick Tips: Practical Ways to Manage Attention Deficit Disorder Successfully.
Nadeau, G. N.& Briggs, S. H. School Strategies for ADD Teens
Pfiffner, L. J. All About ADHD: The Complete Practical Guide for Classroom Teachers.
Reif, S. F.: How to Reach and Teach ADD/ADHD Children


For Further Information you may contact Dr. Jeffrey Bernstein and/or :
1). C.H.A.D.D National Office
499 Northwest 70th Avenue, Suite 101
Plantation, Florida 33317
(800) 233-4050
http://www.chadd.org

2). A.D.D. WAREHOUSE
(800) 233 - 9273
http://www.addwarehouse.com

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When ADHD Combines with Depression

Depression Can Often Co-exist with AD/HD

Studies suggest that between 10-30 percent of children with AD/HD, and 47 percent of adults with AD/HD, also have depression. ADHD and depression can be a very harmful combination that interferes with effective coping for life's inevitable challenges. Both genetics and environment play a role. AD/HD children may not be invited to play at other children’s homes because of past difficulties with disruptive behavior or accidents, or may not be chosen to be on sports teams or to participate in games. They often may be ignored or teased by peers. This can squash the AD/HD child’s self-esteem, leaving the AD/HD child discouraged. About one in four may become clinically depressed. While all children have bad days where they feel down, depressed children may be down or irritable most days. Children with AD/HD and depression may also withdraw from others, stop doing things they once enjoyed, have trouble sleeping or sleep the day away, and lose their appetite. A big problem associated with depression is toxic thinking where individuals criticize themselves excessively ("I never do anything right!"), and talk about dying ("I wish I were dead"). Adults with ADHD may feel rejected and become depressed from being negatively treated by spouses, peers, and co-workers who are frustrated with them.

Based on my clinical experience, it gets complicated for the ADHD individual, parents, and loved ones when trying understand if problems are due to CHOOSE NOT or CANNOT (e.g., sustain attention, study in a linear, organized manner, and keep things in order). Too often ADHD children, teens, and adults are viewed as Choosing Not and they are negatively labeled as LAZY or IRRESPONSIBLE. This can contribute to depressed feelings. Individual counseling and family counseling can be of help for improving self-esteem, putting problems in perspective, gaining appropriate expectations, and arriving at new solutions. Negative self-talk needs to be challenged and countered with more positive thinking. In some cases, stimulants (such as Ritalin) can be combined safely with antidepressants such as fluoxetine (Prozac) — these children not only feel better but also function better at school. Newer antidepressants such as bupropion (Wellbutrin) and venlafaxine (Effexor) have been found effective in some individuals with AD/HD alone and may additionally benefit those individuals with both AD/HD and depression.



References/Related Reading

CHAAD FACT SHEETS at CHADD.org

The ADHD-Autism Connection : A Step Toward More Accurate Diagnoses and Effective Treatments
by Diane Kennedy, Rebecca Banks (2002)


When Your Child is Hyperactive: New Ways to Cope with ADHD in Your Family
by David B. Hawkins (2002)

Driven to Distraction : Recognizing and Coping With Attention Deficit Disorder from Childhood Through Adulthood
by Edward M. Hallowell, John J. Ratey (1994)

Pliszka, S.R. (1998). Comorbidity of Attention-Deficit/Hyperactivity Disorder with Psychiatric Disorder: An Overview. Journal of Clinical Psychiatry 59 (Supplement 7): 50-5B.

Wachtel, A. (1998). The Attention Deficit Answer Book. New York: Plume (Penguin).
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Self esteem

Here are some simple but very important ways a parent can enhance a child's self esteem:

  • Let your child express him/herself - allow him/her to share feelings without fear of reprisal.
  • Give your children privacy. Let them be in command of a certain area of the house (i.e. bedroom). Let them enjoy their own company.
  • Allow your children freedom to do tasks their own way. At times they may fail- be supportive.
  • Teach your child how to set realistic expectations. Teach them to break a big goal into many small goals which seem less overwhelming. This will decrease the amount of "I can'ts."
  • Work on your own self-esteem. Children learn from your actions.
  • Allow your child to develop an interest or hobby that is appealing to them. Make an effort to expose your child to new things and let them decide what interests him/her.
  • Teach your child to be responsible. Do not let your child "off the hook", follow through consistently.
  • Work on your communication skills - you may be sending out "mixed signals".
  • Have respect for your child's body. Never insult your child by criticizing his/her body or expressions.
  • Keep your spouse/significant other as a top priority. Children should not be the main and only source of happiness and fulfillment. When fighting with your spouse, if in front of children, make sure they see you make up.
  • Never withhold love as a means of punishment. When your child does something you do not approve of, communicate clearly that it is the action that you disapprove of, not your child.
  • To the extent possible, give your child your undivided attention. Don't try to do two things at once - it minimizes the importance of their words.
  • Give affection and communicate love to your child often - not just when it's convenient for you.
  • Put yourself in your child's shoes. Remember that all problems are relative in importance.
  • Have reasonable expectations for your child. Children are not an extension of their parents - they are unique individuals. Have respect for individual talents and do not push them to be what they cannot or do not want to be.
  • Use "I" statements instead of "you" or "you always" statements. Try not to constantly evaluate.
  • Be consistent in your discipline. If possible, both parents should be practicing consistent discipline.
  • Try to foster patience in your child. This will make it easier for your child to feel good about him/herself in a world where patience is truly a virtue.
  • Accentuate the positive. Give plenty of encouragement and show appreciation when possible.
  • Teach your child what is unique about your family. Share family stories, customs.

Suggested Reading:

Bernstein, J. (1994) Painless Parenting: Raising Children You Want to Live With (Audio Cassette).

Branden, N. (1992). The Power of Self-Esteem, Deerfield, Fl: Health Communications

Covey S. The Seven Habits of Highly Effective Families.

Dinkmeyer, McKay, & Dinkmeyer (1997): The Parents Handbook:, AGS, Circle Pines, MN.

Goleman, D (1995). Emotional Intelligence.

Helmstetter, S. (1986). What to Say When You Talk to Yourself, New York: Simon and Schuster.

Phelan, T. (1997) 1 - 2 -3 Magic: Training Your Children To Do What You Want (2nd Edition).

Phelan, T. Self-Esteem Revolutions in Children: Understanding and Managing the Critical Transitions in Your Child's Life.

Ritchey, W. & Isaacs, S. (1989). I Think I Can, I Know I Can, New York: St. Martin's Press.

Silberman, M. (1995). When Your Child is Difficult, Champaign, Ill: Research Press.

Seligman, M. (1996). The Optimistic Child..

Schaefer & Millman. (1988). How to Help Children with Common Problems.

Vernon, A & Al-Mabuk, R. (1995). What Growing Up is All About, Champaign, Ill: Research Press.


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Anxiety Disorders

Anxiety Disorders In Children & Adolescents Fact Sheet

What are anxiety disorders?

Anxiety disorders are the most common mental health problem in America. They affect as many as one in 10 young people. Unfortunately, these disorders are often difficult to recognize, and many who suffer from them are either too ashamed to seek help or they fail to realize that these disorders can be treated effectively.

Two major studies involving thousands of children and college students show that anxiety has increased substantially since the 1950's. The findings appear in the December 2001 issue of the American Psychological Association's (APA) Journal of Personality and Social Psychology. The results of the studies suggest that cases of depression will continue to increase in the coming decades, as anxiety tends to predispose people to depression. Other implications of the findings suggest that alcohol and drug abuse will continue to be an increasing problem too, because anxiety usually precedes the onset of substance abuse.

Anxiety disorders cause people to feel excessively frightened, distressed, and uneasy during situations in which most others would not experience these symptoms. Left untreated, these disorders can dramatically reduce productivity and significantly diminish an individual's quality of life. Anxiety disorders in children can cause lead to poor school attendance, low self-esteem, deficient interpersonal skills, alcohol abuse, and adjustment difficulties. Researchers now believe that the childhood-onset anxiety syndromes foreshadow adult anxiety disorders.

What are the most common anxiety disorders?

Panic Disorder—Characterized by panic attacks, panic disorder results in sudden feelings of terror that strike repeatedly and without warning. Physical symptoms include chest pain, heart palpitations, shortness of breath, dizziness, abdominal discomfort, feelings of unreality, and fear of dying. Children and adolescents with this disorder may experience unrealistic worry, self-consciousness, and tension.

Post-traumatic Stress Disorder—Persistent symptoms of this disorder occur after experiencing a trauma such as abuse, natural disasters, or extreme violence. Symptoms include nightmares, flashbacks, the numbing of emotions, depression; feeling angry, irritable and distracted; and being easily startled.

Obsessive Compulsive Disorder (OCD)---OCD is characterized by repeated, intrusive, and unwanted thoughts (obsessions) and/or rituals that seem impossible to control (compulsions). Adolescents may be aware that their symptoms don't make sense and are excessive, but younger children may be distressed only when they are prevented from carrying out compulsive habits. Compulsive behaviors often include counting, arranging and rearranging objects, and excessive hand washing.

Phobias—A phobia is a disabling and irrational fear of something that really poses little or no actual danger. The fear leads to avoidance of objects or situations and can cause feelings of terror, dread, and center around particular objects (e.g., certain animals such as dogs) or situations (e.g., heights or enclosed spaces). Common symptoms for children and adolescents with "social" phobia are hypersensitivity to criticism, difficulty being assertive and low self-esteem.

Generalized Anxiety Disorder—Chronic, exaggerated worry about everyday, routine life events and activities that lasts at least six months is indicative of generalized anxiety disorder. Children and adolescents with this disorder usually anticipate the worst and often complain of fatigue, tension, headaches, and nausea.

Other recognized anxiety disorders include: agoraphobia, acute stress disorder, anxiety disorder due to medical conditions (such as thyroid abnormalities), and substance-induced anxiety disorder (e.g., too much caffeine).

Are there any known causes of anxiety disorders?

Although studies suggest that children and adolescents are more likely to have an anxiety disorder if their caregivers have anxiety disorders, it has not been shown whether biology or environment plays the greater role in the development of these disorders. High levels of anxiety or excessive shyness in children six to eight may be indicators of a developing anxiety disorder.

What treatments are available for anxiety disorders?

Effective treatments for anxiety disorders include medication, specific forms of psychotherapy (behavior therapy and cognitive behavioral therapy), family therapy, or a combination of there. Cognitive–behavioral treatment involves the young person's learning how to deal with his or her fears by modifying the way he or she thinks and behaves by practicing new behaviors. Ultimately, parents and caregivers should learn to be understanding and patient when dealing with children with anxiety disorders. Effective treatments are available. Adult understanding and compassion are essential to augment the effectiveness of any treatment program.

Sources and further information:

National Alliance for the Mentally Ill (www.nami.org)

American Psychological Association (www.apa.org)

Anxiety Disorders in Children And Adolescents (John March, 1995)

Treatments That Work With Children (Chrisopherson & Mortweet, 2001)The above article appeared in ADHD RESEARCH UPDATE (http://www.helpforadd.com)

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Depression

A Fact Sheet on Depression in Children and Adolescents

Among both children and adolescents, depression leads to interpersonal and psychological difficulties that persist long after the depressive episode is resolved. In adolescents there is also an increased risk for substance abuse and suicidal behavior. Unfortunately, these disorders often go unrecognized. Signs of depressive disorders in young people often are viewed as “normal” mood swings typical of a particular developmental stage. In childhood, boys and girls appear to be at equal risk for depressive disorders; but during adolescence, girls are twice as likely as boys to develop depression. Children who develop major depression are more likely to have a family history of the disorder, often a parent who experienced depression at an early age, than patients with adolescent- or adult-onset depression. Adolescents with depression are also likely to have a family history of depression, though the correlation is not as high as it is for children.

Scope of the Problem

Up to 2.5 percent of children and up to 8.3 percent of adolescents in the U.S. suffer from depression.

Depression in young people often co-occurs with other mental disorders, most commonly anxiety, disruptive behavior, ADHD, or substance abuse disorders, and with physical illnesses, such as diabetes .

Suicide

Depression in children and adolescents is associated with an increased risk of suicidal behaviors. This risk may rise, particularly among adolescent boys, if the depression is accompanied by conduct disorder and alcohol or other substance abuse. In 1997, suicide was the third leading cause of death in 10- to 24-year-olds.

Clinical Characteristics

Children and young adolescents with depression may have difficulty in properly identifying and describing their internal emotional or mood states. For example, instead of communicating how bad they feel, they may act out toward others, which may be interpreted simply as misbehavior or disobedience. Research has found that parents are less likely to identify major depression in their adolescents than the adolescents themselves.

Symptoms of Major Depressive Disorder Common to Adults, Children, and Adolescents

  • Persistent sad or irritable mood
  • Loss of interest in activities once enjoyed
  • Significant change in appetite or body weight
  • Difficulty sleeping or oversleeping
  • Psychomotor agitation or retardation
  • Loss of energy
  • Feelings of worthlessness or inappropriate guilt
  • Difficulty concentrating
  • Recurrent thoughts of death or suicide

Signs That May Be Associated with Depression in Children and Adolescents

  • Frequent physical complaints such as headaches, muscle aches, stomachaches or tiredness
  • Frequent absences from school or poor performance in school
  • Talk of or efforts to run away from home
  • Outbursts of shouting, complaining, unexplained irritability, or crying
  • Being bored
  • Lack of interest in playing with friends
  • Alcohol or substance abuse
  • Social isolation, poor communication
  • Fear of death
  • Extreme sensitivity to rejection or failure
  • Increased irritability, anger, or hostility
  • Reckless behavior
  • Difficulty with relationships
    1. Psychotherapy. Recent research shows that certain types of psychotherapy, particularly cognitive-behavioral therapy (CBT), can help relieve depression in children and adolescents. CBT is based on the premise that people with depression have distortions in their views of themselves, the world, and the future. Another specific psychotherapy, interpersonal therapy (IPT), addresses disturbed personal relationships that may contribute to depression. IPT has not been well investigated in youth with depression. However, one controlled study found that IPT led to greater improvement than clinical contact alone. Regardless of the form of counseling, children and adolescents may feel quite vulnerable and their trust first needs to be earned. At the same time, depending on the child or adolescents concern’s, well timed integration of family counseling sessions can be of great value to reduce family/parenting issues that may be fueling the youth’s depression.
    1. Medication. Research by the National Institute of Mental Health (NIMH) suggests that some of the newer antidepressant medications, specifically the selective Seritonon reuptake inhibitors (SSRIs), have been shown to be safe and efficacious for the treatment of severe and persistent depression in young people, although large scale studies in clinical populations are still needed. However, the NIMH also emphasizes that medication as a first-line course of treatment should be considered for children and adolescents with severe symptoms that would prevent effective psychotherapy or those with psychosis, and those with chronic or recurrent episodes. Following remission of symptoms, continuation treatment with medication and/or psychotherapy for at least several months may be recommended, given the high risk of relapse and recurrence of depression.

It is very important for parents to understand their child's depression and treatment. Parents can be told that depression in youth is not uncommon, and be reassured that appropriate treatment with psychotherapy, medication, or the combination can mean improvements at school, with peers, and at home with family.

Sources for the above Fact Sheet: National Institute of Mental Health, American Psychological Association, American Psychiatric Association

Websites for Further Information:

National Institute of Mental Health: www.nimh.nih.gov

American Academy of Child and Adolescent Psychiatry: www.aacap.org

American Psychiatric Association: www.psych.org

American Psychological Association: www.apa.org

Child & Adolescent Bipolar Foundation: www.bpkids.org


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Sexual Trama

Important Points in Understanding Sexual Trauma

"Our bodies weep the tears our eyes refuse to shed."

--Dan Millman

The above quote speaks to the complications of sexual abuse. Clinical findings presented at a conference I recently attended included the following:

1) Trauma memory is stored differently than ordinary memory-- in the right hemisphere in fragmented, unintegrated form, separate from the brain's language center. This is why traditional talk therapy MUST be modified with visual modalities to help clients effectively address the trauma.

2) Early trauma causes "synaptic pruning" that results in hyperarousal , the misreading of social cues, and difficulty with self-soothing and calming. Children who have been abused can have problems with affect regulation. They become easily overstimulated and have difficulty calming themselves. This also affects the ability to experience positive emotional states. In line with the quote above, synaptic pruning can affect attachment, empathy, and the capacity to regulate body pain. People with childhood trauma DO hurt more.

3) Survivors of childhood trauma are particularly vulnerable to revictimization. There is considerable shame associated with the revictimizations (usually not seen as revictimizations by the client). Often, there is more pain associated with the recycling or reenactment of the trauma than with the original trauma. It is imperative that the survivor is educated to this common occurrence. Many survivors never learned or were taught to ignore the warning signs (and triggers).

4) Children who have been sexually traumatized often act out their trauma on others-neighbors, siblings, friends, toys or animals.

5) Girls are more likely to have been sexually traumatized by family/extended family predators.

6) Boys are more likely to be sexually traumatized by predators outside the family.

7) 27% of women and 16% of men report being sexually abused prior to age 18.

8) Indicators of sexual abuse in children can include: stealing, fire-starting, bedwetting, torture of animals, short attention span, compulsive behaviors, age inappropriate sexual curiosity/knowledge/behavior, social withdrawal, powerlessness, extreme fear of doctors and dentists, unkempt, stained underwear, promiscuity in teens and preteens, frequent masturbation, and fear of certain people/certain gender.

References/Related Reading:

Bass (1988) The Courage to Heal

Bass (1993) Beginning to Heal

Davis (1991) Allies in Healing: When the person you love was sexually abused as a child

Melissa Bradely (2002) Counseling Victims of Sexual Abuse: The three stages of healing [conference manual]

Gil (1992) Outgrowing the pain together: A book for spouses and partners of adults abused as children

Rothchild (2000) The body remembers

Lew (1988) Victims no longer

Lew (1999) Leaping Upon Mountains- Men proclaiming victory over sexual child abuse


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Your Child's Moody Blues

Reasons for Your Child's MoodyBlues and Other Difficult Behaviors

Children need to belong. This helps them feel accepted. To do this they use positive behavior or misbehavior. Typically, when children act moody and/or misbehave, they feel discouraged. They find that misbehavior helps them to feel a sense of belonging. When children misbehave, they have a goal. They may feel the only way to belong is by:

  • Attention
  • Power
  • Revenge
  • Display of Inadequacy
  • Attention

When children feel that they cannot get attention in useful ways, they get it from misbehaving. Misbehavior can be both active (whining, refuse to cooperate, break something), or passive (do nothing).

Power

Some children seek power. They do this to communicate "I am in control"; "You can't make me." To accomplish this children may yell or silently not budge. Or, children may conform to a parent's request but do it in a slipshod manner. This can be quite exasperating for parents who may find themselves quite angry and hurt. If the parent yells or fights back, the child fights back. If the parent gives in, the child wins the power struggle.

Revenge

Some children want to be the boss but win in a power struggle with their parents. These children feel that the best way to belong is to get even. The child may do or say something hurtful or stare angrily at the parent. This results in mutually experienced angry, hurt feelings.

Displaying Inadequacy

For some children, the way to belong is to get others to leave them alone. Their behavior says, "I can't do it." This can influence the parent to also give up, leading the child to feel he met his goal.

Note: Children who consistently appear moody for a persistent amount of time (two to four weeks) may benefit from a consultation with a mental health professional.

Adapted from: The Parents Handbook: Dinkmeyer, McKay, & Dinkmeyer, AGS, Circle Pines, MN 1997.


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Behavior

A Thumbnail Sketch of Infant and Toddler Behavior

Four Weeks

Compared to birth, breathing and heart rate stabilized. Sleeps more definitively and wakes more decisively. Reacts positively to comforts and satisfactions. Not quite ready to smile socially. Begins to impose wants on outside world. 

Twelve Weeks 

A period of disequilibrium. Placed on stomach on a flat surface, the baby at this age struggles fruitlessly and awkwardly. This period often has feeding and sleep problems. Often increase in crying at this period. 

Sixteen Weeks 

A period of relative equilibrium. Large increase in motor activities and vocalizing. Becoming a social being. Feeding no longer foremost on mind and can sometimes wait for feeding. Likes to be held and propped up to see world. Eyes follow a moving object. Hands reach out for objects. 

Twenty Weeks 

A period of disequilibrium. Strains to sit up. Likely to cry when mother or father leaves. Aware of strangers. 

Twenty Eight Weeks

Equilibrium period. Behavior patterns and emotions are in good focus. Wants to touch. Wants to be held and stand up and bounce. Enjoys banging simple objects. Smiles to intimates and strangers. Likes to hear voices. The increased physical abilities at this time help to lower frustration from earlier periods. 

Thirty Two Weeks

Another period of disequilibrium. New awareness at this age makes for increased sensitivity. Postural difficulties lead to frustration. 

Forty Weeks 

Socially responsive. Considerably more verbal, able to imitate simple syllables, e.g., da-da. Posturally more agile, can go to prone from sitting. Can crawl around and pull self to standing position. 

One Year (Fifty Two Weeks) 

Typically an age of reasonably smooth functioning. Rate of growth begins to slow down. Can cruise around holding on to objects for support. May take a few steps with hands supported. 

Fifteen Months 

Disequilibrium. Trying to do many things at once. Gets into everything. Beginning to vocalize or point out wants. Bottle to cup transition begins for some. Moods shift more often. 

Eighteen Months

Not particularly mindful of adult requests. This is not because child is bad but because there are many abilities not yet mastered. Low frustration tolerance. Understands far more words than can say. Quick temper tantrums and need to have everything "now." 

Two Years 

Marked period of equilibrium. More sure of self in language and in motor activity. Affectionate, likes to please others. (But beware of the disequlibrium at age two and a half. Rigid, demanding and strong emotions are apt descriptors of two and half years old). 

Adapted from: Ilg and Bates. Child Behavior from Birth to Ten, Gesell Institute


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Discipline Strategies

Discipline Strategies for Caregivers of Children

When considering strategies for discipline, caregivers often ask themselves these questions: Am I disciplining in a way that hurts or helps this child’s self-esteem? Will my discipline help the child develop self-control? The following suggests methods and language that can be used in handling common situations involving young children.

Methods Of Discipline That Promote Self-Worth:

1. Show that you recognize and accept the reason the child is doing what, in your judgment, is the wrong thing:

"You want to play with the truck but..."

"You want me to stay with you but..."

This validates the legitimacy of the child's desires and illustrates that you are an understanding person. It is also honest from the outset: The adult is wiser, in charge, not afraid to be the leader, and occasionally has priorities other than those of the child.

2. State the "but":

"You want to play with the truck, but Jerisa is using it right now." "You want me to stay with you, but right now I need to (go out, help Jill, serve lunch, etc.)."

This lets the child know that others have needs, too. It teaches perspective taking, and may lead the child to develop the ability to put himself in other people’s shoes. It will also gain you the child’s respect, for it shows you are fair. And it will make the child feel safe; you are able to keep him safe.

3. Offer a solution:

"Soon you can play with the truck."

One-year-olds can begin to understand "just a minute" and will wait patiently if we always follow through 60 seconds later. Two- and three-year-olds can learn to understand, "I’ll tell you when it’s your turn," if we always follow through within two or three minutes. This helps children learn how to delay gratification but does not thwart their short-term understanding of time.

4. Often, it’s helpful to say something indicating your confidence in the child’s ability and willingness to learn:

"When you get older I know you will (whatever it is you expect)."

"Next time you can (restate what is expected in a positive manner)."

This affirms your faith in the child, lets her know that you assume she has the capacity to grow and mature, and transmits your belief in her good intentions.

5. It is most effective to begin a corrective statement positively, then address the undesirable behavior:

"We are gentle with our friends, it is not okay to hit." (Gently stroke).

"Toys need to be used properly. Puzzle pieces are not for throwing, let's put them in their places together. "(Offer help).

This sets firm limits, yet helps the child feel that you two are a team, not enemies.

6. Toddlers are not easy to distract, but frequently they can be redirected to something that is similar but OK.

Carry or lead the child by the hand, saying,

"That’s the gerbil’s paper. Here’s your paper."

"Peter needs that toy. Here’s a toy for you."

This endorses the child’s right to choose what she will do, yet begins to teach that others have rights, too.

7. Avoid accusation. Even with babies, communicate in respectful tones and words. This prevents a lowering of the child’s self-image and promotes his tendency to cooperate.

8. Instead of saying no, offer acceptable choices:

"No! Rosie cannot bite Esther. Rosie can bite the rubber duck or the cracker."

"No, Jackie. That book is for teachers. You can have this book or this book."

This encourages the child’s independence and emerging decision-making skills, but sets boundaries. Children should never be allowed to hurt each other. It’s bad for the self-image of the one who hurts and the one who is hurt.

9. If children have enough language, help them express their feelings, including anger, and their wishes. Help them think about alternatives and solutions to problems.

Adults should never fear children’s anger:

"You’re mad at me because you’re so tired. It’s hard to feel loving when you need to sleep. "When you wake up, I think you’ll feel more friendly."

"You feel angry because I won’t let you have candy. I will let you choose a banana or an apple. Which do you want?"

This encourages characteristics we want to see emerge in children, such as awareness of feelings and reasonable assertiveness, and gives children tools for solving problems without unpleasant scenes.

Establish firm limits and standards as needed. Until a child is 1 ½ or almost 2 years old, adults are completely responsible for his safety and comfort, and for creating the conditions that encourage good behavior. After this age, while adults are still responsible for the child’s safety, they increasingly, though extremely gradually, begin to transfer responsibility for behaving acceptably to the child. They start expecting the child to become aware of others’ feelings. They begin to expect the child to think simple cause/effect thoughts (provided the child is guided quietly through the thinking process). This is teaching the rudiments of self-discipline.

11. To avoid confusion when talking to very young children, give clear, simple directions in a firm, friendly voice. This will ensure that children are not overwhelmed with a blizzard of words and refuse to comply as a result.

12. Remember that the job of a toddler, and to some extent the job of all young children, is to taste, touch, smell, squeeze, tote, poke, pour, sort, explore, and test. At times toddlers are greedy, at times grandiose. They do not share well; they need time to experience ownership before they are expected to share. They need to assert themselves ("No," "I can’t," "I won’t," and "Do it myself"). They need to separate to a degree from their parents, that is, to individuate. One way they do this is to say no and not to do what is asked; another is to do what is not wanted.

If adults understand children in this age range, they will create circumstances and develop attitudes that permit and promote development. Self discipline is better learned through guidance than through punishment. It’s better learned through a "We are a team, I am the leader, it’s my job to help you grow up" approach than through a "me against you" approach.

  • Creating A Positive Climate Promotes Self-Discipline
  • Creating a positive climate for the very young involves:
  • spending lots of leisurely time with an infant or child;
  • sharing important activities and meaningful play;
  • listening and answering as an equal, not as an instructor (for example, using labeling
  • words when a toddler points inquiringly toward something, or discussing whatever topic
  • the 2-year-old is trying to tell you about);
  • complimenting the child’s efforts: "William is feeding himself!" "Juana is putting on her
  • shoe!" (even if what you are seeing is only clumsy stabs in the right direction); and smiling,
  • touching, caressing, kissing, cuddling, holding, rocking, hugging.

Harmful, Negative Disciplinary Methods

Criticizing, discouraging, creating obstacles and barriers, blaming, shaming, using sarcastic or cruel humor, or using physical punishment are some negative disciplinary methods used with young children. Often saying, "Stop that!" "Don’t do it that way!" or "You never..." is harmful to children’s self-esteem. Such discipline techniques as removal from the group, or isolation in a time-out chair or a corner, may have negative consequences for the child.

Any adult might occasionally do any of these things. Doing any or all of them more than once in a while means that a negative approach to discipline has become a habit and urgently needs to be altered before the child experiences low self-esteem as a permanent part of her personality.

Good Approaches To Discipline

  • increase a child’s self-esteem.
  • allow her to feel valued.
  • encourage her to feel cooperative.
  • enable her to learn gradually the many skills involved in taking some responsibility for what
  • happens to her.
  • motivate her to change her strategy rather than to blame others.
  • help her to take initiative, relate successfully to others, and solve problems.

Credits

The above information was adapted from literature from the Office of Educational Research and Improvement, U.S. Department of Education.


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TOXIC THINKING AND PARENTING

Q and A with Author of Liking The Child You Love Jeffrey Bernstein, Ph.D.

How did you first discover that parents think toxically?

I am a yeller in recovery. And after twenty years of working with frustrated parents I saw something crucial was missing. I mean really missing! Many had been to past counselors with their kids only to end up more discouraged and frustrated in trying to make their relationship work. One day, during one of my sessions, I heard the frustrations of a mom exclaiming about here daughter, “I love her but I am scared because I realize I don’t like her.” Hoping your child’s challenging ways will just fade away on their own is a recipe for relationship disaster. I discovered parents became more effective with their kids when they focused on changing their own toxic thoughts instead of overly focusing on their child’s problems.

How is toxic thinking different from negative thinking?

Negative thinking is not extreme, distorted and far off-base like toxic thoughts are. For example, saying to yourself, “He is just not taking me as seriously as he used to and I am not feeling good about this.” is a negative. A toxic thought would be, “He never listens and with that attitude he will fail in life.”

Our toxic thoughts tend to create big time problems for our parenting success, and even more scary for the success of our children. Think about how many adults are still in emotional pain while remembering upsetting sound bites or reeling from the disconnects with their own parents!

Why do you say that until parents are free from toxic thinking, their kids will be less understood.

Trying to work on your parenting relationship without first getting rid of toxic thoughts is like building a house on quicksand, the only place you’re going is down. Unless you clear the fog of toxic thinking from your own mind, you can’t see your child in a fair, realistic manner, you really don’t stand a chance in being empathetic to him, and you can’t work through problems. And let’s face it, kids won’t open to parents who they perceive as unfairly judging them.

You talk about the fact that culturally, we are prone to think toxically as parents. You also say that most parents have shame about their toxic thoughts. Please explain.

Fairly tales and Hollywood have kept alive the myths that parenting is supposed to be like greeting card images. Myths such as these lead us to have unrealistic expectations of ourselves as parents and of our kids. Because deep down we are afraid of our kids struggling, being rejected, and getting hurt, we tend to be mistakenly (and toxically) fill in blanks about our children’s intentions and actions that we don’t understand.

In your book, you identify nine of the most common toxic thought patterns. Can you tell us about them? Are there any that are more common?

Whether it is the Always or Never Trap (e.g., “You never care about school”) or Label Gluing (e.g., “You’re lazy”) or Should Slamming (“You should always tell me how you really feel!”) all nine of the toxic thought patterns share one thing in common. They are distortions that are very unfair, and very damaging to parenting. The scariest thing about all of the toxic thinking patterns is that like cancer or high blood pressure, they can develop without even knowing they are there—until major parent-child rifts occur.

You say that if parents can think their way out of liking their child, they can think their way back into liking him. Specifically how can parents break the toxic thinking cycle?

First, parents need to have what I call relationship “mindfulness.” This means more than simple awareness. I share in the book how to develop mindfulness skills to help parents stay vigilant to avoid damaging interactions and to keep the mindset of appreciation and empathy of your child and well. A big part of Mindfulness is education about what toxic thoughts are and how to zap them. Practicing these skills opens to the door to return to empathy-the emotional glue that keeps parents and kids connected. Emotional equilibrium and communication gets restored once these are in place.

What can you do if you have a child that really is difficult?

It is fascinating, but most kids across the land feel that they are not understood the way they would like to be. Even the most defiant ones desperately want ot feel understood. I think it is essential to get rid of scorecard and not focus on waiting for your child to make changes, even though it is natural to want him or her to. In most cases, you’ll be amazed how much your parenting satisfaction begins and ends with you dealing with your own toxic thoughts. It is a dance and often when a parent eases up on the tensions, the child or teen follows suit. At the same time, major learning problems, active addictions and physical abuse represent examples of some problems parents and children may have that, if not dealt with, will block being able to get toxic thinking under control.

Why is parenting so hard?

Again, you are driven by glamorized expectations of what you think childrearing SHOULD be like, even if you are reluctant to admit it. Most upset and frustrated parents have very distorted ways of thinking about their kids. It is hard to want to give your child the benefit of the doubt when you are harboring toxic thoughts such as “he never thinks of anyone but himself,” “I can never count on her to follow through on anything,” or “She is the reason I have to take anti-anxiety medications.”

Talking Points For the Media

  • Learn how we create more misery for ourselves as parents than our kids create for us.
  • How you think impacts how you parent
  • Unhealthy thoughts about your kids lead to unhealthy parenting
  • Your negative parenting self talk that occurs outside your immediate awareness will surprise you.
  • You kids pick up on how your think.
  • How you think is what you model to your kids
  • Demystify why it is inevitable for parents and kids to have miscommunications, misinterpretations, misunderstandings and lots of other "misses." In our heads, we tend to overestimate and catastrophasize these events. I call this process Toxic Thinking per the examples below… - He never thinks of me, just himself. - She always has to be right.. - He needs help. His emotions are out of control.
  • Find out how to overcome, as seen in the above examples, the tendency to take isolated negative events and “go global.” Too often, we look to confirm the negatives in our partners more than the positives.
  • Find out what emotional ghosts are and how to stop them from messing up your parenting efforts.
  • You need a license to drive and to get it you can study a manual. There is no such manual to guarantee parenting success. No one teaches you about toxic thinking and few people figure it out on their own.
  • Parenting is a fertile breeding ground for toxic thoughts because of the inevitable anxiety parents have over their kids “turning out okay”.
Related articles:
 
Middle School Malaise
 
Change Your Mind About Mental Health
 
Parenting: The Teen Years


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